For Medical Facilities

Caldwell County EMS provides hospitals, nursing homes, and hospice centers with professional, compassionate, and punctual pre-facility and inter-facility medical transports and care. Our EMS Billing Division has developed comprehensive medical transportation solutions to meet the needs of both large and small institutions.

To assist us in making the process of scheduling a transport, below you will find forms and information, required for facilitating such transportation. Word versions of each form can be found under the document tab on the website, PDF versions listed below and in documents.

Advanced Beneficiary Notification Form(ABN Form) PDF Version HERE - The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. The facility must complete the ABN as described below, and deliver the notice to affected beneficiaries or their representative before providing the items or services that are the subject of the notice. The ABN must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. Employees or subcontractors of the notifier may deliver the ABN. ABNs are never required in emergency or urgent care situations.

Physician Certification Statement for Non-Emergency Ambulance Services (PCS Form) PDF Version HERE - The Physician Certification Statement (PCS) is the written order certifying the medical necessity of non-emergency ambulance transports. Ambulance providers are required by federal regulations (Code of Federal Regulations, §410.40, Coverage of Ambulance Services) to obtain a physician certification statement (PCS) from the attending physician for non-emergency ambulance trips (scheduled or non-scheduled) before submitting a claim to Medicare. A PCS is required in advance for non-emergency scheduled or repetitive ambulance services. The date on the PCS can be no more than 60 days prior to the date the ambulance transportation occurs.

When is a PCS required?

Facilities Form (Non-Emergency Transport Form) PDF Version HERE - The Facilities Form is to be completed for all Non-Emergency Transports for patients who do not have Medicare i.e. Patients with Medicaid, Private Insurance or No Coverage. The Facilities Form must be verbally reviewed with the beneficiary or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to consider other options and make an informed choice.